Culture-bound syndromes (CBS) are psychiatric conditions recognisable and limited to a particular culture. These syndromes often lack an underlying organic cause and are congruent with cultural practices, beliefs and social norms. Outbreaks of CBS can occur as a behavioural epidemic, with peer-to-peer learning and characteristics of mass hysteria. Models for CBS include the concept of bioattentional looping, whereby pervasive cultural beliefs provoke anxiety, the surveillance of the body for symptoms, and the reinforcement of these cultural beliefs once symptoms are identified [1]. CBS may also have an important role to play in the formulation of a narrative identity within distinct cultures. Debates as to whether CBS is a misnomer if all psychiatric conditions have a culture driven element continue even as the DSM V replaces the term with ‘Cultural Concepts of Distress’.
Examples of CBS (many of which are included in the DSM V) include the following:
- Koro, a condition where individuals believe their genitals are retracting in their body in Asia, the Middle East and Nigeria.
- Amok, sudden unprovoked acts of violence preceded by brooding with complete amnesia afterwards in South Asia, African and New Guinea.
- Pibloktoq, a dissociative state affecting female members of indigenous populations in the circumpolar region, characterised by impulsive behaviours which may be followed by seizures.
- Latah, a trance like state characterised by startle reactions, echolalia, echopraxia in Malaysian women following a traumatic event.
- Dhat, a belief that semen is being passed in the urine resulting in lethargy, anxiety, hypochondria and sexual dysfunction amongst men in the Indian subcontinent.
- Wendigo, the belief that one has been transformed into a creature that eats human flesh amongst Native American populations.
- Susto, the belief that one’s soul has been stolen from the body during a traumatic event in Central and South American communities.
- Tajin Kyofusho, a social phobia based on a fear of embarrassing others with one’s appearance or behaviours common in Japan.
- Frigophobia, a fear of cold rooted in traditional Chinese cosmology.
- Hikikomori, a phenomenon of extreme social withdrawal common in middle aged men responsible for Japan’s ‘lost generation’.
- Maladi dyab, where psychosis, depression, social and academic failure are the consequences of sorcery sent maliciously by those with interpersonal envy in Haiti.
- Voodoo death, the belief that curses or hexes can result in death at a predicted time, observed in various cultures.
- Brain fag, where painful somatic symptoms and cognitive disruption are attributed to a period of prolonged studying in Nigeria.
- Kyal Cap, ‘wind attacks’ prompted by a change in environment and causing dizziness, shortness of breath and numbness due to the belief that wind has entered the blood in Cambodian culture.
When viewed through the prism of the empiricism and rationality of Western medicine, these syndromes appear subclinical, exotic and peculiar, and widely inexplicable. However, it is precisely because of these biases that the cultural elements to certain conditions are overlooked despite substantial geographical variety in incidence (bulimia, anorexia, body dysmorphia, repetitive strain injuries, post menstrual syndrome, irritable bowel syndrome, musculoskeletal back pain, depression, seasonal affective disorder [2-10]). Disorders such as Truman Syndrome, a paranoid delusion in which a person believes their life is a staged reality show, and Wind Turbine Syndrome, a range of adverse effects reported by those living in proximity to wind turbines, read as culture bound yet fail to fall under its umbrella in classification.
Below a surface level of morbid curiosity towards CBS lies a host of thought-provoking explanations as to why these conditions exist in the first place: our same vulnerability to suggestion which has been evidenced by the placebo and nocebo effects, our fundamental need to create a coherent narrative for ourselves, and the importance of culture as such a powerful psychological force it can make men believe their penises have disappeared despite all physical evidence to the contrary. Creating a dichotomy between psychiatric disorders which are “real” and those which are socially constructed or fabricated will not serve our ability to understand the complex factors which drive CBS. If the generation of psychiatric and somatic symptoms by a pre-existing belief in them is a universal rule, then the term ‘Culture Bound Syndromes’ is redundant.
Koro epidemics come in waves. The first modern recorded outbreak in 1967 started in Hong Kong when a 16-year-old boy was rushed to a general hospital after consuming a pork bun by his parents, who were convinced that his recent meal had led to an episode of suo yang, the ancient Chinese term for penile retraction first documented in 400 BC [11]. Reassurances from the Ministry of Health only seemed to inflame the situation, pork sales nosedived and reported cases skyrocketed as the horrifying sight of a slightly shrunken penis in bathtub water could transport a local population intoxicated by panic to hospital emergency waiting rooms. 469 cases were recorded, but the real number of those affected by Koro during this period is likely to be much higher [12]. The crisis only ended after regional newspapers agreed to stop publishing cases at the request of public health officials. In 1984 the largest recorded epidemic of Koro affected the Isle of Hainan in China, where an evil fox spirit was believed to be wandering the island stealing men’s genitals. 2,000 to 5,000 people were affected, whilst two people died: a baby from being protectively fed pepper juice and a young girl from being beaten to death during an exorcism [13]. From 1997-2003 a total of 36 accused ‘penis thieves’ were killed at the hands of mobs in West Africa [14]. In areas such as Nigeria, where human body parts are frequently sold at markets, fears of kidnapping permeate into daily newspaper headlines, and witchcraft is a widespread practice, men and women often engage in protective behaviours during periods of Koro paranoia [15]. These include clenching or holding onto genitals, clutching the breast and seeking out protection through superstition, witchcraft and medicines. Dr Wu Chaundong, who investigated a recent outbreak of Koro in Sanya in 2011, does not believe that Koro has disappeared just because hospital cases have declined: “The culture changes only when people change their minds. Doctors can go to rural places and educate people, with medical theory that your penis cannot shrink into your body. But the people still believe” [16].
Researchers are no closer to understanding Pibloktoq than they were when the condition was first described in Polar exploration literature in 1894 [17]. Inuit populations do not appear to stigmatise the condition, in which affected individuals during the ‘excitement’ phase may exhibit impulsive behaviours such as tearing off clothes, screaming, shouting and running out into the snow. Instead, Piblotoq is referred to by indigenous populations as an indiscriminate illness that can affect any person at any time and is allowed to run its course without interference [18]. Many hypotheses exist for the condition, ranging from vitamin A toxicity, vitamin D deficiency, to geographical isolation – none have been scientifically tested or proven. This absence of explanation leaves an uncomfortable truth: through the projection of a biomedical model, the partitioning of Pibloktoq symptoms away from its cultural context and the outside stress created by their own presence, western researchers have invented Pibloktoq [19]. After interrogating all written records of the condition, historian L Dick concluded that Pibloktoq was no more than a “catch all rubric under which polar explorers lumped various Inuit anxiety reactions, symptoms of physical illness, expressions of resistance to patriarchy or sexual coercion, and shamanistic practice” [20]. The reason why the idea of Pibloktoq has persisted may be a simple one – our inability to see beyond our own horizons and recognise what is considered ‘healthy’ in another society.
You probably can’t predict your own death, yet our beliefs directly shape our own mortality. Putting the small number of anecdotal reports of Voodoo Death aside [21, 22], there is a discrete version of Voodoo Death which plays out in all of us every day. Within the Framingham Heart Study, women who believed they were at risk of heart disease were 3.6 times more likely to die of heart attacks than women with identical risk factors who were not [23]. In a large cohort study, those with a negative view of ageing died on average 7.5 years before those with a positive view [24]. Even stranger, there is a consistent spike in death from cardiac arrest on the fourth of every month only amongst people of Chinese and Japanese ethnicity, who commonly hold the idea of four as an unlucky number [25]. Pre-existing ideas around whether the state of stress is harmful or non-harmful causes completely different physiological profiles of stress responses [26]. A 1998 study of 28,000 Americans over 8 years found that high levels of stress increased the risk of death by 43% only in those who believed stress was harmful to their health. Those who reported high levels of stress but did not believe their stress was harmful to their health had the lowest risk of death of any subpopulation within the study, even lower than those who reported low levels of stress [27].
Since 1977, 117 Hmong immigrants in the United States have died from Sudden Unexpected Nocturnal Death (SUND) after leaving Vietnam and no one knows why [28]. Autopsies were unable to identify a medical explanation except conduction abnormalities of the heart. 97% of Hmong immigrants when interviewed were familiar with the concept of dab tsog, a group of nocturnal evil spirits which established burial rites protected against [29]. Vulnerable and separated from relatives who died without a grave or their rituals observed, 58% of those interviewed reported at least one ‘attack’ from dab tsog during the night [29]. It is thought SUND in this community may represent the expression of an extreme nocebo effect. One of the earliest studies demonstrating the nocebo effect involved a group of patients given sugar water who were told it would make them vomit. 80% of patients vomited [30]. The placebo effect can be equally as powerful. When two groups of patients rated their pain after being given a placebo medication post wisdom tooth operation in a study at the University of California, one group was unknowingly administered naloxone, an opioid receptor antagonist. The clear difference in pain scores could only be explained by endogenous opioid production, the analgesic response to placebo exposed by being blocked in one group but not the other [31]. Even when participants are told they are taking a placebo there can still be a physiological benefit. In an open label placebo study for IBS, knowingly ingesting a placebo still resulted in significant improvement in IBS symptom severity scores compared to no treatment controls [32]. These examples serve to illustrate a point: biofeedback loops are not purely biological.
Culture may be one of the hardest words to define in the English language. Early attempts to classify a definition of the word by anthropologists Alfred Kroeber and Clyde Kluckholn left them with 164 different descriptions ranging from “all transmitted social learning” to “all products of nongenetic efforts at adjustment” [33]. Some ethnologists such as EB Tylor define culture as a process of acquisition, where “knowledge, belief, art, morals, law, custom” by man converge to that of his society [34]. Others, such as Franz Boas, see the development of culture as an independent process which spontaneously arise from historical conditions, allowing ideas and practices to diffuse geographically [35]. Perhaps some of the tension in being able to define what culture is can be relieved by identifying what it is not. Culture is not related to education, class or privilege. Nor is it indiscriminate to geography. Culture does not arise without human connection.
Some of the most important decisions in our lives are spread socially. In studies of social learning, when a named friend develops obesity the likelihood the participant follows suit is 57%, far greater than for a sibling (40%) or a spouse (37%) [36]. This directional flow of behaviour termed as the ‘peer effect’ has been repeatedly demonstrated in smoking habits, marital breakdown and feelings of happiness, loneliness, and depression [37-43]. Once we pair social learning with a biochemical response to psychological suggestion, the aetiology of culture bound syndromes shifts into focus.
Culture bound syndromes represent the complex interplay between culture, narrative and the manifestation of both physical and psychological symptoms from pre-existing ideas. The same interplay is recognisable in mass psychogenic illnesses, notable examples of which are the Dancing Plague of Strasbourg in 1518, Havana Syndrome in 2016, and Resignation Syndrome amongst modern refugees [44-46]. Culture is immersion; the stories we hear are never as powerful as the ones we see. These conditions are still real to those who experience them, even as the term we use to describe them grows obsolete. ‘Fugue’, ‘hysteria’ and ‘multiple personality disorder’ were all consigned to history’s bookshelf as ephemeral diagnostic terms tied to the social conditions from which they came from [47]. Perhaps as we begin to appreciate the role of culture in all psychiatric conditions, the term ‘culture bound syndromes’ will be placed on that shelf as well.
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